Provider Demographics
NPI:1760672893
Name:ROOSEVELT DENTAL CARE II P.C.
Entity Type:Organization
Organization Name:ROOSEVELT DENTAL CARE II P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:OSTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-334-0431
Mailing Address - Street 1:9553 ROOSEVELT AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-8028
Mailing Address - Country:US
Mailing Address - Phone:718-334-0431
Mailing Address - Fax:718-334-0676
Practice Address - Street 1:9553 ROOSEVELT AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-8028
Practice Address - Country:US
Practice Address - Phone:718-334-0431
Practice Address - Fax:718-334-0676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02850695Medicaid